Upfront: Detecting child abuse in general practice

This second article in our series on children and young people in New Zealand who have been abused or neglected, aims to provide primary care professionals with an awareness of some of the indicators of child abuse and ways to intervene.

Children who come to the attention of Child, Youth and Family are some of New Zealand’s most vulnerable people.
They have been exposed to significant trauma and are often disconnected from regular health and education services. They
are likely to have high physical, behavioural and emotional needs that create a barrier to them achieving their potential.

In the Budget 2011, the Government announced funding of $30 million over four years to provide services to this group
of young people. This money will enable the national implementation of the Gateway Assessment programme and will support
the development of several mental health initiatives.

This second article in our series on children and young people in New Zealand who have been abused or neglected, aims
to provide primary care professionals with an awareness of some of the indicators of child abuse and ways to intervene.
It also outlines the initiatives that Child, Youth and Family have underway to identify and address the needs of these
children.

Recognising neglect and abuse of children

Neglect is the most common form of abuse

Although the effects of neglect may not be as obvious as physical abuse, the consequences can be just as serious.

Neglect can consist of:

Physical neglect – not providing the necessities of life

Neglectful supervision – leaving children without someone safe looking after them

Emotional neglect – not giving children the comfort, attention and love they need

Medical neglect – the failure to ensure their health needs are met

Educational neglect – allowing chronic truancy, failure to enrol children in school, or inattention
to their special education needs

Signs of neglect may include:

A rough and uncared for appearance

Persistent skin disorders or infections

Lack of supervision (and as a consequence risk of injury, conduct problems and offending)

Falling behind in educational achievement and attendance

Indiscriminate attachment to adults

Emotional abuse is a component of all abuse and neglect

Emotional abuse is a pattern of behaviour where the child is rejected and put down. They may be isolated, constantly
degraded and criticised or negatively compared to others. The effects of emotional abuse may only become evident as the
child gets older and begins to show difficult or disturbing behaviours.

Signs of emotional abuse, in addition to those from neglect, include:

Sleep problems – including bed-wetting or soiling

Frequent physical complaints – real or imagined

Anxiety – including poor self esteem, inability to cope in social settings and sometimes obsessive
behaviour. May include self-harming and suicidal ideation.

Physical abuse is any behaviour which results in physical harm to a child

Signs of physical abuse include:

Unexplained bruises, welts, cuts and abrasions – particularly in unusual places like the face, trunk,
buttocks or the backs of the legs. Concern should be raised when the explanations change or do not make sense.

Unexplained fractures or dislocations – especially worrying are fractures to the head or face, and
hip or shoulder dislocations, particularly in young infants.

Burns – anywhere on the body are concerning, and if not easily explained need to be notified. Be
mindful of burns in the shape of an object like a stove ring or iron, cigarette marks or rope burn.

Sexual abuse is any act where an adult or a more powerful person uses a child or young person for a sexual purpose

Sexual abuse may be consensual or not, and can happen within or outside the family. Most sexual abuse is perpetrated
by someone the child knows and trusts.

Sexual abuse may include physical sexual acts, exposure to pornographic material and internet sites, sexually oriented
texting or sexual conversations. It often begins with some form of grooming – preparing the child for sexual contact by
lowering their inhibitions and gaining their trust.

The following signs are an indication that a child may be being sexually abused:

Physical signs – unusual or excessive itching, bruising, lacerations, redness, swelling or bleeding
in the genital or anal area, urinary tract infection, blood in the urine or faeces, painful urination or other signs
of being sexually active. When pregnancy or a sexually transmitted disease is identified, abuse must always be considered,
especially in girls aged under 16 years

Age inappropriate sexual play, knowledge or interest – and other unusual behaviour like sexually
explicit drawings, descriptions and talk about sex

Fear of a certain person or place – children might be trying to express their fear without saying
exactly what they are frightened of, so listen carefully, and take what they say seriously. Some children may purposefully
try to make themselves unattractive, or try to feel clean through obsessive washing.

Risk factors for abuse and neglect

A range of risk factors have been identified for abuse and neglect of children. These risk factors are also positively
correlated with the development of severe antisocial behaviour in older children and adolescents.

Risk factors for abuse and neglect include:

Parental history (particularly the mother) of anxiety, depression or other mental illness or a history of sexual abuse

Families under financial stress

Problem use of drugs or alcohol

Parental lack of social support or social isolatation

Family violence

Children left home alone

Parents with poorly developed parenting skills - often younger mothers and those who have been in the care of CYF
as children themselves

Abnormal parental expectations or distorted perception of the child

The following signs of family behaviour may raise concerns about the risk of abuse or neglect:

Unrealistic expectations of an older child’s ability to care for younger siblings may indicate
neglect. It can cause stress and anxiety to children who are not capable of taking on these responsibilities.

Humiliation of children or young people is a powerful form of emotional abuse. Children may be subjected
to fierce and personal criticism, often in front of siblings or peers, or they may be given demeaning tasks to carry
out.

Isolation – when a family, or an adult and child, are isolated it is hard for them to get support,
which makes them more vulnerable to harm or neglect. Signs of isolation may include: failing to keep appointments, lack
of engagement with regular health providers, refusing to let an agency visit or moving frequently.

Medical neglect – where parents do not assume a “health advocacy” role for their children

Dependency – professionals can unsuspectingly become involved in meeting the increasing demands from
parents for practical and emotional support. This focus on the parents often overshadows the children’s needs and
the parents sometimes compete with their children to be the main subjects of concern.

What to do if you are concerned

If you are concerned about a child, it is not so important to be able to categorise the type of abuse you think may
be going on – it is normal to feel uncertain. However, if you notice a pattern forming or several signs that make you
feel worried, this could be an indication that something is going wrong.

There are often no black and white answers to how you should react to evidence or suspicion of abuse or neglect. Usually
your instinct will tell you something is wrong, and you may have clues, but you won’t know for sure.

The main thing is that you take notice and take action. If there are problems, they are likely to go on until someone
speaks up. Children cannot speak up for themselves and the people involved may be too ashamed, distressed or caught up
in the situation to ask for help.

Do not hope that someone else will notice and do something about it. As professionals, we are the ones who work with
children, know them and their families, and play an important role in keeping them safe. Each professional involved with
the child often only has a part of the picture. Taking action allows the whole picture to be put together across a range
of professionals and agencies.

If you are worried about a child:

Trust your instincts – don’t be afraid of getting it wrong

Spot the warning signs – familiarise yourself with the signs of abuse and neglect

Listen – take notice and listen carefully to what people say. Are the family asking for help?

Talk to your colleagues – are other health and education colleagues working with this family? Are
they also noticing signs that something is not right?

Talk to Child, Youth and Family – our social workers are trained to work out what kinds of problems
a family might be having, and find the best ways to help keep their children safe. You might want to talk your concerns
through with one of our hospital based social workers, someone from your local site, or our contact centre social workers.

If you are worried that a child is not safe or being well looked after, phone
0508 FAMILY (0508 326 459). If you think the situation may be life-threatening, phone the Police on 111.

Identifying and addressing health needs: Child, Youth and Family initiatives

Gateway Assessments for all children and young people with high needs

From 1 July, 2011, Child, Youth and Family will be rolling out the new Gateway Assessment process with the Ministries
of Health and Education.

Social workers will ensure all children and young people with high needs have a comprehensive Gateway Assessment. It
is expected that around 4,200 children will meet the criteria for referral each year. This will include all children who
enter non-emergency care, children and young people already in care who have significant health and behavioural needs
and children identified as having high needs at a Family Group Conference.

Over the last two years, Child, Youth and Family and the Ministries of Health and Education have been piloting health
assessments and education profiles across four district health boards – Auckland, Counties Manukau, Lakes and Mid Central.
Nelson Marlborough DHB joined the pilots in April 2011.

Central to the Gateway Assessment process is the Gateway Assessment Coordinator who is employed by the DHB and gathers
together the available background information from the social worker, family, health and education contacts.

Teachers from the child or young person’s school provide a profile of their education engagement and achievement.

One of richest sources of background health data has proven to be the transaction records that the New Zealand Health
Information Service (NZHIS) is able to provide. These reports include birth records, prescribed medications, laboratory
test requests, hospital admissions, mental health contact, PHO enrolment, immunisation records and outpatient events.
ACC also provides a complete record of all reported injuries for the child. The WellChild provider also contributes to
the picture, where they have been involved in the care of the child.

This information provides the leads for the Assessment Coordinator to contact various health practitioners and piece
together the fragmented health record for the child or young person.

The very complex needs of these children means that the health assessment is usually undertaken by a paediatrician with
the assistance of a nurse specialist. Several pilot sites engaged General Practitioners to undertake the assessment, however,
the time requirement (two to three hours), interpretation of screening tools and the mental health and developmental assessments
have proven challenging for primary care. Adolescent assessments are undertaken by youth health practitioners

The output from the assessment is a comprehensive interagency report and recommendations. This report is sent to the
social worker, General Practitioner (where a consistent General Practitioner can be identified), teacher and caregiver.

These children and young people often have health records that are scattered around the country between primary and
secondary care. Health transactions often occur in Accident and Medical Clinics, Afterhours Centres and Emergency Departments.
Child, Youth and Family are exploring opportunities to make the assessment reports and health history available to health
practitioners who subsequently engage with the children. It is envisaged that the Gateway Assessment record could become
the foundation for an ongoing integrated health record.

Everyone involved in ensuring the child’s health and safety will be following their progress. While the social
worker has overall responsibility to monitor and review the child’s development plan with the family while the child
is in care, the primary care provider has a key role in monitoring their growth, development and mental health.

The benefits accruing from the health and education assessment includes:

Families gaining new insights into their child’s health and behaviour that they had not previously understood
- 88% of children who have been assessed had unidentified or unmet health needs.

Connecting these children with primary care and specialist health services

Better information for teachers to help them work with the child in the class room

More integrated information across agencies which strengthen the relationships, leading to more informed planning
and service development

Families, teachers, social workers and health professionals working together

Specialist child health services becoming aware of the needs of the child and advocating on their behalf to access
service (particularly mental health services) to address the child’s needs

The first regions to implement the Gateway Assessment programme will be the health and education pilot sites (see above).
They began providing the revised service on 1 July 2011. This service is designed to ensure that all children with high
needs who come to the attention of Child, Youth and Family have a comprehensive assessment of their health and education
status as early in their development as possible. By identifying and addressing their needs it is expected that Child,
Youth and Family can facilitate a material difference to the child’s educational achievement and social participation.
It is anticipated that this programme will reduce their involvement in the criminal justice system.

Mental health services

Child, Youth and Family was allocated funding in the Budget 2011 to increase the availability of mental health services
for children and young people in care.

This funding will be used to implement a primary care based child mental health service targeted to meet the needs of
children who have emotional and behavioural disorders but do not meet the criteria for specialist mental health services.
It will also be used to expand, over the next four years, the number of Intensive Clinical Support Services available
for young people with mental health and behavioural challenges who are in the care of Child, Youth and Family.

Child, Youth and Family are currently recruiting the team that will develop these services in consultation with the
sector.

Money was also allocated in the Budget 2011, over four years, to develop a dedicated youth forensic mental health and “Alcohol
and other Drugs” service across New Zealand. This will provide community youth forensic teams, increase Youth Court
liaison services and provide secure inpatient beds.

Measuring outcomes

As a condition for approving the additional funding for these services, the Government required Child, Youth and Family
to develop a clear set of outcome measures. While these measures are still in development, they will explore the outcomes
in terms of education, health and social welfare. Health measures will include indicators such as immunisation rates,
changes in mental health screening scores, teen pregnancy rates and PHO enrolment.

These outcome measures will enable us all to understand what interventions are successful and how best to address the
needs of New Zealand’s most vulnerable children.